LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events.
LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events.
复制标题
DOI：
10.1016/j.healun.2021.08.001
复制
发表时间：
2021-12
期刊：
影响因子：
--
通讯作者：
Shah P
中科院分区：
文献类型：
--
作者：
Gerhard EF;Wang L;Singh R;Schueler S;Genovese LD;Woods A;Tang D;Smith NR;Psotka MA;Tovey S;Desai SS;Jakovljevic DG;MacGowan GA;Shah P
左心室辅助装置（LVAD）机械地卸载心脏，并与神经激素治疗相结合，可以促进逆转心脏重塑和心肌恢复。据报告，在短期随访期间，微创LVAD停用并将器械留在原位是安全的。器械保留是否会降低长期安全性或恢复的可持续性尚不清楚。这是一项对2010年5月至2020年1月期间达到应答状态（左心室射血分数，LVEF ≥40%和左心室舒张内径，LVIDd ≤ 6.0 cm）并接受择期LVAD停用以恢复心肌的患者进行的双中心回顾性分析。所有患者均行流出道移植物闭合和动力传动系统切除术，LVAD留在原位。排除了因感染或器械血栓形成而紧急停用LVAD的情况。对患者进行了长达三年的连续超声心动图随访。主要临床结局是无心力衰竭住院、LVAD再植入或移植的生存率。在研究期间，515例患者接受了LVAD，29例（5.6%）实现了心肌恢复，12例患者接受了完全器械停用或紧急器械停用，17例患者接受了择期LVAD停用，并被纳入分析。LVAD植入时患者的中位年龄为42岁（四分位距，IQR：25 - 54岁），均患有非缺血性心肌病，5例（29%）为女性。植入LVAD时，中位LVEF为10%（IQR：5 - 15%），LVIDd为6.6 cm（IQR：5.8 - 7.1 cm）。有11个流体动力悬浮离心流（65%）和6个轴流式LVAD（35%）。停用前LVAD支持的中位持续时间为28.7个月（13.5至36.2个月）。与调低研究参数相比，退役后1个月，中位LVEF从55%降至48%（p=0.03），LVIDd从4.8 cm增至5.2 cm（p=0.10）。6个月后逐渐重塑，3年随访时无统计学差异（LVEF 42%，LVIDd 5.6cm）。复发性感染影响了41%的患者，导致3例死亡和1例器械完全取出。1例需要移植的患者发生复发性HF。无HF、LVAD或移植的生存概率在1年时为94%，在3年时为78%。停用LVAD以恢复心肌与无复发性心力衰竭的良好长期生存率以及心室大小和功能的保留长达3年相关。降低复发感染的风险仍然是这种管理策略的重要治疗目标。
Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown. This is a dual-center retrospective analysis of patients who had achieved responder status ((left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to three-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant. During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25 to 54 years), all had a nonischemic cardiomyopathy and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5 to 15%) and LVIDd 6.6 cm (IQR: 5.8 to 7.1cm). There were 11 hydrodynamically levitated centrifugal-flow (65%) and 6 axial-flow LVADs (35%). The median duration of LVAD support prior to decommissioning was 28.7 months (13.5 to 36.2 months). As compared to the turndown study parameters, one-month post-decommissioning, median LVEF decreased from 55% to 48% (p=0.03) and LVIDd increased from 4.8cm to 5.2 cm (p=0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year and 78% at 3-years. LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.
登录
查看更多内容
影响因子：
24
作者：
Jakovljevic DG;Yacoub MH;Schueler S;MacGowan GA;Velicki L;Seferovic PM;Hothi S;Tzeng BH;Brodie DA;Birks E;Tan LB
通讯作者：
Tan LB
影响因子：
4.2
作者：
Puius, Yoram A.;Parkar, Fauziya;Moadel, Renee M.
通讯作者：
Moadel, Renee M.
影响因子：
37.8
作者：
Birks, Emma J.;Drakos, Stavros G.;Rame, Jesus E.
通讯作者：
Rame, Jesus E.
影响因子：
3.4
作者：
Gyoten, Takayuki;Rojas, Sebastian, V;Morshuis, Michiel
通讯作者：
Morshuis, Michiel
影响因子：
158.5
作者：
Birks, Emma J.;Tansley, Patrick D.;Yacoub, Magdi H.
通讯作者：
Yacoub, Magdi H.